Sunday, February 12, 2017

President Harry S. Truman and country
singer Buck Owens both used a familiar ancient idiom – when you grab
hold of a tiger letting go is dangerous.

The Trump administration and the
Republicans in Congress have learned the same lesson the hard way,
they jumped on the health care tiger and now they do not know what to
do.

Where are We At?

The Republicans in Congress have
discovered some hard truths about health care.

U.S. health care is complicated.

The Affordable Care Act is complicated.

Health care economics is complicated.

Budget politics is complicated.

Writing new health care law is
complicated.

Keeping promises is complicated.

Pleasing 325 million people, or even a
slice of that population, is complicated.

So all of the chest thumping and
hollering about “repeal and replace” has so far turned into
hollow noise, because doing something of substance is a lot tougher
than shouting slogans.

What They Don't Know

In six years I
have not encountered a Republican, either face-to-face or through
their media presence, who sounded as if they actually knew what is in
Obamacare and why. I suppose such people exists.

It is all about
the slogans.

“Death panels!”
“Illegal mandates!” “Crushing tax burdens!”

The U.S. health
care system was complicated before the Affordable Care Act, and the
overwhelming complexity of ACA made it much worse. Add to this
thousands of pages of Obama-era regulations and there is a lot to
know about the current health care system.

This cannot be
fixed with slogans.

The GOP Menu (maybe)

Conservative think
tanks and the GOP have been circulating the same ideas for decades.

Health Savings
Accounts – good for the affluent, not so good for anyone else

Interstate sales
of health insurance – does absolutely nothing for consumers,
except expose them to lousy insurance plans - but good for lousy
insurance companies and salesmen

“Market based”
consumer choices – as in buying oncology is like buying a
cheeseburger

Dump ACA
subsidies, replace with tax credits (subsidies!)

Special treatment
for Big Pharma – yes, Congressmen are for sale (both parties)

Send poor people
back to Emergency Departments (which hurts hospitals)

So What Am I Saying?

The GOP does not
have a coherent plan to replace the Affordable Care Act and may never
have such a plan. There will likely be a repeal, total or partial,
but the replace will be difficult.

The GOP might
eventually have a plan to make Rush Limbaugh, the Koch brothers, the
Tea Party and Fox News happy, sort of. Even that may fail.

The GOP has been
blaming ACA for higher consumer costs (higher deductibles and
co-pays) , and may replace ACA with a plan with – you guessed it –
higher deductibles and co-pays,, including for seniors.

Repeal and Replace, or Partial
Repeal and Partial Replace, or Reform and Repair, or ?????

On Super Bowl
Sunday President Trump told Fox News that “repeal and replace”
could take up to a year. Huuuge!

A few days earlier
Rep. Jim Jordan, on the far right wing of Congress, said the total
and complete and quick repeal of ACA was the only viable strategy.
Soon.

In the last ten
days or so “repair” has become a popular word, often in a phrase
such as “reform and repair.” This implies that not all of ACA
would be repealed, some of it would be repealed and new features
would be added as a repair.

Ask ten
Republicans in Congress and get seven or eight different answers.
There is also squabbling about whether health care should be done
before tax reform. The House majority and the Senate majority have
different ideas, and the Senate majority is pretty thin.

So, the GOP has
painted itself into a corner. The GOP could recover, stranger things
have happened in Washington, but as of early February consensus is
not looking either quick or easy, which makes near term legislation
unlikely.

Legislative strategy

IF, repeating IF
the GOP can agree on a plan, the various pieces and parts must
through the legislative process. Some parts could move through
reconciliation, others through the standard legislative process. This
could cause a problem in the Senate.

The Longer Term

House Speak Paul
Ryan has promised to”fix” Medicare.

There are ways to
fix Medicare, but Ryan apparently has no clue. There are serious
reform efforts already in motion to move Medicare from the original
fee-for-service model to a more sophisticated value-based model, the
legislation passed by bipartisan votes.

His approach is to
turn Medicare into a for-profit play pen for insurers and doing
tremendous damage to senior citizens. Wow.